Chronic pain treatment with pregabalin in end stage respiratory failure patients awaiting lung transplantation on ambulatory veno-venous extra corporeal membrane oxygenator support; a series of nine cases.

Background: End-stage respiratory failure is non-treatable with mechanical ventilation and can be treated with veno-venous extracorporeal membrane oxygenators (VV-ECMO). It can also be used as a bridge to lung transplantation or recovery of lung function. This patient group can suffer from chronic pain, which is further exacerbated by painful procedures required as part of treatment. Pregabalin is licensed for chronic neuropathic pain and generalized anxiety disorder. Thus far, it has not been tried in routine analgesia protocols for pain relief of patients on VV-ECMO. Case Series: We included nine patients aged 17-54 years on VV-ECMO awaiting lung transplantation. Exclusion criteria were acute kidney injury and chronic kidney disease. All patients had morphine patient-control analgesia. In addition, pregabalin 50 mg twice daily was initiated in all patients with dose escalation as required. Pain scores and quality of sleep were evaluated daily. All patients experienced significant pain relief, demonstrated by reduced pain scores after treatment commencement. The mean visual analogue scale score was reduced significantly from 6 ± 2 to 3 ± 1. A significant increase in good-quality sleep duration was recorded from 5 ± 1.7 hours per day before to 8 ± 2.1 hours per day after pregabalin treatment. All patients except for two reported reduced anxiety levels of at least 2 ± 1 scale improvement (p <0.05). Conclusions: Pregabalin is an efficient analgesic with accompanying anxiolytic effects in this group of patients with unique characteristics such as high analgesia requirements and exacerbated psychological and emotional stress. HIPPOKRATIA 2023, 27 (1):22-24.

Modular minimally invasive extracorporeal circulation systems; can they become the standard practice for performing cardiac surgery?

Minimally invasive extracorporeal circulation (MiECC) has been developed in an attempt to integrate all advances in cardiopulmonary bypass technology in one closed circuit that shows improved biocompatibility and minimizes the systemic detrimental effects of CPB. Despite well-evidenced clinical advantages, penetration of MiECC technology into clinical practice is hampered by concerns raised by perfusionists and surgeons regarding air handling together with blood and volume management during CPB. We designed a modular MiECC circuit, bearing an accessory circuit for immediate transition to an open system that can be used in every adult cardiac surgical procedure, offering enhanced safety features. We challenged this modular circuit in a series of 50 consecutive patients. Our results showed that the modular AHEPA circuit design offers 100% technical success rate in a cohort of random, high-risk patients who underwent complex procedures, including reoperation and valve and aortic surgery, together with emergency cases. This pilot study applies to the real world and prompts for further evaluation of modular MiECC systems through multicentre trials.

Minimal extracorporeal circulation reduces the incidence of postoperative major adverse events after elective coronary artery bypass grafting in high-risk patients. A single-institutional prospective randomized study.

Coronary artery bypass grafting (CABG) using minimal extracorporeal circulation (MECC) has been associated with an improved short-term clinical outcome compared to conventional extracorporeal circulation (CECC). The aim of this study was to evaluate the impact of MECC compared to CECC on postoperative major adverse events in high-risk patients undergoing elective coronary revascularization procedures. Two hundred patients undergoing elective CABG were randomized into two groups. In Group A (n=100), MECC was used while Group B (n=100) included patients who were operated on CECC. The incidence of postoperative major adverse events (myocardial infarction, renal failure, stroke, death) was the primary end-point of the study. MECC was associated with a 77% relative risk reduction in the incidence of major adverse events compared to CECC (p=0.004). The rate of major adverse events occurring in the high-risk patient subgroup (preoperative left ventricular ejection fraction ≤40%, age >65 years, EuroSCORE II >5) operated on with MECC was significantly lower in comparison to their CECC counterparts. Based on our results, cardiac centres should be encouraged to use MECC as the standard circuit when performing elective coronary procedures, even in a high-risk population.

Intramyocardial implantation of autologous bone marrow-derived stem cells combined with coronary artery bypass grafting in patients with ischemic cardiomyopathy: a pilot study.

BACKGROUND: Ischemic cardiomyopathy has the distinctiveness of irreversible myocardial damage with scar tissue formation and mainly impaired perfusion of the remaining viable myocardium. We present results of the first series of patients with severe ischemic cardiomyopathy managed in our institution with intramyocardial implantation of autologous bone marrow stem cells at the time of coronary artery bypass grafting. The aim is to evaluate feasibility and safety of the procedure in our institution. PATIENTS AND METHODS: Nine patients with severe ischemic cardiomyopathy scheduled for elective coronary artery bypass grafting were managed with concurrent intramyocardial autologous bone marrow stem cells injection in pre-defined viable peri-infarct areas that showed poor perfusion and could not be grafted. Detailed mapping of infracted and hibernating myocardial segments was performed in all patients with single photon emission computed tomography segmental analysis. RESULTS: There was no perioperative 30-day mortality. Improvement was evident in left ventricular ejection fraction which was increased significantly from 31.3% preoperatively to 42.4%, 46.6% and 52.5% at 3, 6 and 12 months respectively. Postoperative thallium scintigraphy revealed increased perfusion in myocardial segments corresponding to areas of stem cell injection and a net reduction in the estimated infarct size at 6 and 12 months in 5/8 (62.5%) patients. CONCLUSIONS: Preliminary data from this pilot study show that intramyocardial administration of bone marrow stem cells in patients undergoing coronary bypass grafting for ischemic cardiomyopathy is safe and associated with an improvement in left ventricular function and enhanced reperfusion of non-viable myocardial territories.

Detection of tract formation for prevention of bile peritonitis after T-tube removal. Case report.

Bile leakage after removal of T-tube is a relatively rare complication caused by inadequate tract formation around the tube. We report a case of bile peritonitis after removal of a latex T-tube. The patient underwent reoperation and a new T-tube was introduced. The T-tube was removed six weeks later. Immediately after removal of the tube, the cutaneous ostium of the tube was catheterized with a thin Nelaton catheter. The administration of gastrographin showed the presence of an intact tract. The removal of the t-tube was uneventful. We would propose this method for detecting the tract after removal of the T-tube in order to prevent severe bile leakage after inadequate tract formation.

Study of the carrying angle of the human elbow joint in full extension: a morphometric analysis.

This study measured the carrying angle of the elbow joint in full extension in 600 students, using the supplementary angle to that between the longitudinal axis of the arm and that of the forearm. The mean carrying angle was 12.88 degrees +/-5.92: 10.97 degrees +/-4.27 in men and 15.07 degrees +/-4.95 in women. The carrying angle changes with skeletal growth and maturity. The angle is always greater on the side of the dominant hand. We confirmed the inverse relationship between the carrying angle and the intertrochanteric diameter. Also, the type of constitution influences the value of the carrying angle, especially in women.

Preincisional local infiltration of levobupivacaine vs ropivacaine for pain control after laparoscopic cholecystectomy.

BACKGROUND: Postoperative pain is less intense after laparoscopic surgery than after open surgery. However, patients may gain additional benefit from a preincisional local infiltration of anesthetic. The aim of this study was to compare the analgesic efficacy of two local anesthetics, ropivacaine and levobupivacaine, for tissue infiltration as a means of improving postoperative pain control after laparoscopic cholecystectomy. METHODS: Using a randomized, double-blind study design, 57 American Society of Anesthesiologists (ASA) I and II patients scheduled for laparoscopic cholecystectomy were randomly assigned to receive local infiltration with 0.9% saline solution (Placebo group, n = 18), ropivacaine 1% (Rop group, n = 20), or levobupivacaine 0.5% (Lev group, n = 19). The local anesthetic was administered, prior to trocar placement, using the same technique and delivering the same volume (20 ml) for all three groups. The anesthetic technique was standardized for all groups. Postoperative pain was rated at 2 h, 4 h, and 24 h postoperatively by visual analogue scale (VAS) score. Cumulative analgesic consumption and adverse effects were also recorded. Data were analyzed by analysis of variance (ANOVA), followed by a post hoc test. RESULTS: The Lev and Rop groups did not differ significantly in their VAS scores at 2 h postoperatively, but the Lev group experienced significantly ( p < 0.001) less pain than the Placebo and Rop groups at 4 h and 24 h postoperatively. The Rop group registered significantly lower VAS scores ( p < 0.001) than the Placebo group at 4 h postoperatively. Additionally, the consumption of analgesics was significantly lower in the Lev group than in the Rop ( p < 0.01) and Placebo ( p < 0.001) groups, and patients in the Rop group consumed significantly less analgesics ( p < 0.001) than the to patients in the Placebo group. CONCLUSION: Local tissue infiltration with levobupivacaine is more effective than ropivacaine in reducing the postoperative pain associated with laparoscopic cholecystectomy.

Intrahepatic lithiasis as a late complication of hepaticojejunostomy.

The development of intrahepatic lithiasis proximal to a bilodigestive anastomosis is rare. We report a case of intrahepatic lithiasis of the right hepatic duct, which developed almost 6 years after a hepaticojejunostomy performed for an iatrogenic lesion of the common hepatic duct. The patient experienced repeated episodes of acute cholangitis and was treated with intracorporeal lithotripsy and dilation of the stenosis.

Sufentanil or clonidine for blunting the increase in intraocular pressure during rapid-sequence induction.

BACKGROUND AND OBJECTIVE: The aim was to determine if the intravenous administration of sufentanil or clonidine before the induction of anaesthesia could obtund the increase of intraocular pressure associated with rapid-sequence induction. METHODS: Thirty-two ASA I-II patients with no history of eye illness scheduled for elective non-ophthalmic surgery were randomly assigned to receive either sufentanil 0.05 microg kg(-1) i.v. (Group A, n = 15) or clonidine 2 microg kg(-1) i.v. (Group B, n = 17) prior to induction. General anaesthesia was induced with thiopental (5 mg kg(-1)) followed by succinylcholine 1 mg kg(-1) to facilitate tracheal intubation. The general anaesthetic technique was standardized in both groups. Intraocular pressure was measured using the Schioetz tonometer just before the succinylcholine administration (t0), just before tracheal intubation (t1) and immediately after intubation (t2). Mean arterial pressure and heart rate were recorded at the same time intervals. RESULTS: Intraocular pressures were similar in both groups at t0, but the sufentanil group had significantly lower values compared with the clonidine group just before (t1) and immediately after tracheal intubation (t2). CONCLUSIONS: Sufentanil is effective in blunting the increase in intraocular pressure caused by rapid-sequence induction with succinylcholine, while clonidine did not seem to have any effect in intraocular pressures just before (t1) and just after (t2) intubation.

Tropisetron vs ondansetron for prevention of postoperative nausea and vomiting after laparoscopic cholecystectomy: a randomized double-blind, placebo-controlled study.

BACKGROUND: Postoperative nausea and vomiting are observed in increased frequency after laparoscopic surgery. This study was performed in order to compare the efficacy of two 5-hydroxytryptamine-3 (5-HT3) receptor antagonists, ondansetron and tropisetron, in preventing postoperative nausea and vomiting (PONV) after laparoscopic cholecystectomy. METHODS: Using a randomized, double-blind study design, 87 ASA I and II patients scheduled for laparoscopic cholecystectomy were randomly assigned to receive 4 mg ondansetron (Group A, n = 29), 5 mg tropisetron (Group B, n = 31), or placebo (Group C, n = 27) intravenously (IV) before induction of anesthesia. The end points evaluated were frequency of nausea, nausea intensity rated on a scale from 1 (mild) to 5 (most severe), frequency of vomiting, and need for rescue antiemetics. These parameters were measured immediately after surgery (0 h), at 3 h, 6 h, and 12 h postoperatively. RESULTS: The frequency of nausea was significantly higher in group A (31.2%) compared to group B (14%) at 12 h postoperatively (p <0.01). However, patients of group A had significantly lower nausea scores at 3 h postoperatively compared to group B. Postoperative vomiting occurred in 13.8% of patients in group A and 9.6% of patients in group B throughout the whole study period (p = n.s.). The need for rescue antiemetics was similar between groups A and B. Both groups were superior to placebo concerning all studied parameters. CONCLUSION: Our results show that ondansetron may be more effective in controlling nausea intensity during the first 3 h after laparoscopic cholecystectomy, while tropisetron has a longer-acting activity, with a major impact on nausea frequency at 12 h postoperatively.

Incidence of abdominal wall hernias in patients undergoing aortic surgery for aneurysm or occlusive disease.

BACKGROUND: The aim of this study was to compare the incidence of abdominal and incisional hernias in patients with abdominal aortic aneurysm (AAA) versus patients with aortoiliac occlusive disease (AOD). PATIENTS AND METHODS: The study included retrospectively 121 patients, who underwent elective aortic surgery due to AAA (n = 63) or AOD (n = 58) in the period between January 1998 and January 2000. The patients were examined for the presence of abdominal hernias upon admission, as well as for the development of incisional hernias on follow-up. RESULTS: The incidence of inguinal hernias was significantly higher in the group AAA (21/6-33.3%) compared to the group with AOD (6/58-10.3%) (p < 0.01). The incidence of other abdominal wall hernias (umbilical, epigastric or miscellaneous hernias) was also significant higher in AAA group. Furthermore, the incidence of inguinal hernias was significantly higher in the subgroup of patients with an aneurysm diameter more than 6 cm (41.5% vs 18.2%, p < 0.05). The mean follow-up of the patients was 1.7 +/- 0.3 years. 7 cases of incisional hernia were noted in the AAA group (11.1%) and only 2 cases in the AOD group (3.4%) (p < 0.05). The size of the aneurysm had no influence on the incidence of incisional hernias in the AAA group. CONCLUSION: We conclude that there seems to be an increased incidence of abdominal wall hernias as well as postoperative incisional hernias in patients undergoing aortic surgery for aneurysm disease compared with aortoiliac occlusive disease.

Continuous monitoring of arterial blood gases and pH during laparoscopic cholecystectomy using a Paratrend sensor.

BACKGROUND: The safety of laparoscopic procedures has been studied broadly. The effects on cardiopulmonary function and reliable methods of monitoring concentrate more interest. METHODS: A prospective study in 22 consecutive patients with ASA I and II was designed. The continuous assessment of alterations of arterial blood gases, pH, arterial pressure and heart rate during laparoscopic cholecystectomy by carbon dioxide pneumoperitoneum American technique was achieved using an intra-vascular multi-parameter sensor Paratrend. RESULTS: Statistically significant increase of both PaCO2 and PE.CO2 in parallel and a corresponding decrease of pH were found in correlation with the duration of the pneumoperitoneum. The values of PaO2, Sat O2, base excess, H-CO3, mean arterial pressure and heart rate showed no statistically significant alterations at any time throughout the procedure. No differences were noted between younger patients and in the elderly or between patients with ASA I and II. CONCLUSIONS: Intra-arterial blood-gas sensor ensures continuous on-line monitoring, but no abnormal and threatening changes occur during laparoscopic cholecystectomy in otherwise healthy people.

Preincisional intravenous low-dose ketamine and local infiltration with ropivacaine reduces postoperative pain after laparoscopic cholecystectomy.

BACKGROUND: The preincisional use of ketamine combined with local tissue infiltration with Ropivacaine may reduce noxious input during surgery. The goal of this study was to examine whether this combination improves postoperative pain control after laparoscopic cholecystectomy. METHODS: A total of 55 patients were randomly assigned to one of three groups. Group 1 received placebos preincisional. Group 2 received preincisional saline IV and local infiltration with 20 ml ropivacaine (10 mg/ml). Group 3 received preincisional ketamine 1 mg/kg IV and local infiltration with 20 ml ropivacaine (10 mg/ml). Postoperative pain was rated at 0, 3, 6, 12, 24, and 48 h postoperatively by visual analogue scale scores (VAS). Cumulative analgesic consumption and time until first analgesic medication request were recorded. RESULTS: Group 3 experienced significantly (p < 0.05) less pain than group 2 at 6 h and 12 h postoperatively. Groups 2 and 3 did not differ significantly by VAS at 0 h, 3 h, 24 h, and 48 h. Group 1 had significantly higher VAS scores than groups 2 and 3 at 0 h, 3 h, 6 h, 12 h, and 24 h postoperatively. The consumption of analgesics was significantly higher in group 1 than in groups 2 and 3. Although the consumption of analgesics was higher in group 3 than in group 2, this difference did not reach statistical significance. The time to first request for analgesics was significantly longer in groups 2 and 3 than in group 1, with no statistical difference between groups 2 and 3. CONCLUSION: Preincisional treatment with low-dose IV ketamine and local infiltration with ropivacaine 1% reduces postoperative pain after laparoscopic cholecystectomy.

Small-dose S(+)-ketamine reduces postoperative pain when applied with ropivacaine in epidural anesthesia for total knee arthroplasty.

UNLABELLED: Reduction of nociceptive input through blockade of N-methyl-D-aspartate (NMDA) receptors has been reported. We compared the effects of epidural S(+)-ketamine versus placebo on postoperative pain in a randomized, double-blinded study in 37 patients undergoing unilateral knee arthroplasty. After lumbar epidural anesthesia with ropivacaine (10 mg/mL, 10-20 mL), 19 patients received 0.9% epidural saline, and 18 patients received 0.25 mg/kg epidural S(+)-ketamine 10 min before surgical incision. After surgery, patient-controlled epidural analgesia with ropivacaine was provided. During the first 8 h after surgery, visual analog scale pain rating was similar between groups. Twenty-four and 48 h after surgery, patients anesthetized with ropivacaine had higher visual analog scale ratings at rest and during movement (P < 0.05) than patients anesthetized with S(+)-ketamine and ropivacaine. Forty-eight hours after surgery, patients anesthetized with ropivacaine also consumed more ropivacaine (558 +/- 210 mg) (P < 0.01) than those anesthetized with S(+)-ketamine and ropivacaine (319 +/- 204 mg). Adverse events were similar between groups. Patients who received S(+)-ketamine and ropivacaine rated the quality of their pain therapy better than those who received ropivacaine alone (P < 0.05). We conclude that the combination of S(+)-ketamine and ropivacaine in epidural anesthesia increases postoperative pain relief when compared with ropivacaine. IMPLICATIONS: Epidural S(+)-ketamine applied with ropivacaine before surgery is a rational approach to decrease injury-induced pain sensitization. Epidural blockade with an N-methyl-D-aspartate receptor antagonist and a local anesthetic may provide better analgesia in the postoperative period than a local anesthetic alone.